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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 95-99

A study of type, pattern, and clinical profile of retained musculoskeletal foreign bodies of extremities in a tertiary care hospital of North India


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
C/o Dr. Y.P.S. Pangtey, Ganga Vihar, Malli Bamori, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_9_18

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  Abstract 

Background: The presence of foreign body in musculoskeletal tissue is a major concern for the patient and treating doctor with regard to its varied presentations and appropriate management. Both metallic and nonmetallic foreign bodies have been studied extensively with special emphasis on its detection by various imaging modalities and unusual presentations of retained foreign ones. An early detection and retrieval is the mainstay of management, leading to an uneventful recovery. It also prevents subsequent complications of neglected, missed, or retained foreign bodies. The increased indulgence in recreational and industrial activities in recent times has increased prevalence and scope of penetrating injuries with various objects. Detailed data regarding patterns and presentations of various foreign body retention of musculoskeletal tissue, both acute and chronic, thus are helpful to format an anticipatory or preventive workup. Furthermore, the knowledge of the types of common foreign bodies in a region helps in drafting investigative and ameliorative public health strategies.
Materials and Methods: The current study is a retrospective account of pattern and presentation of non-firearm foreign bodies managed in a tertiary care teaching hospital within a defined period. Besides it, patient characteristics and relevant details of trauma and associated findings were listed with at least 4-month follow-up.
Results: Male sex, upper extremity, and left side of body were commonly involved. There was predilection for acral parts such as hand and feet. Agricultural and industrial setup was the common scenario associated with the injuries, and vegetative foreign bodies were mostly found followed by metallic ones among others.
Conclusion: The study highlights various aspects of acute or chronic foreign body retention in clinical settings and is helpful to know type, pattern and presentation in a geographical region.

Keywords: Complication, diagnosis, exploration, foreign body, glass, metal, penetrating wound, splinter, treatment, wood


How to cite this article:
Dharmshaktu GS, Singh B, Jhan A, Singhal A, Bhandari SS. A study of type, pattern, and clinical profile of retained musculoskeletal foreign bodies of extremities in a tertiary care hospital of North India. Saudi Surg J 2018;6:95-9

How to cite this URL:
Dharmshaktu GS, Singh B, Jhan A, Singhal A, Bhandari SS. A study of type, pattern, and clinical profile of retained musculoskeletal foreign bodies of extremities in a tertiary care hospital of North India. Saudi Surg J [serial online] 2018 [cited 2018 Dec 11];6:95-9. Available from: http://www.saudisurgj.org/text.asp?2018/6/3/95/240917


  Introduction Top


Accidental foreign body penetration is a common emergency problem with emphasis on prompt detection and appropriate management to mitigate late complications. A sizeable number to the tune of 38% in one study has been found to be missed at initial presentation.[1] Quick and appropriate management goes a long way to ensure optimal healing and functional outcome of amputation cases. Broadly, the foreign bodies can be classified as accidental, including metallic or nonmetallic types and iatrogenic including hospital goods such as sponges or small instruments. One newer pattern has been added to the list as pediatric behavioral problem called as self-embedding behavior.[2],[3] A comprehensive audit of types and variation of presentation is required for better understanding of the problem and to devise ways to prevent or treat them. The availability of imaging modalities such as ultrasonography (USG) or magnetic resonance imaging (MRI) has played an instrumental role in cases of radio-opaque bodies not appreciable on conventional radiographs. Awareness and prompt emergency consultation, in current times, though have been instrumental in their early retrieval and thus decreasing the burden of retention. However, the risk of getting injured with one or the other sort of foreign body is persistent in industrial work environment, agriculture fields, or dense vegetative geographical terrain. The effective documentation of similar cases is the basic step to know the burden and pattern of this clinical entity to be prepared well to treat them.


  Materials and Methods Top


A retrospective study of medical records and supplementary materials such as radiographs and other ancillary imaging reports was evaluated regarding cases with embedded acute or long-standing musculoskeletal foreign body presented in our department as an out-patient or emergency case during June 2014–December 2016. All cases irrespective of age, sex, and other covariables were included after informed consent at the time of treatment for record keeping and future publication along with the one for operative intervention. The cases with acute presentation with palpable or radiologically evident features were removed in minor operation theater under local or regional anesthesia. The elective surgery was limited for those requiring exploration, deep-seated or those with additional complications. The injuries were strictly limited to nonfirearm in nature with a clear history of a certain foreign body injury (acute and retention) in most cases. Acute cases were included with an arbitrary limit of 6 weeks at the time of presentation from the time of injury and the rest were categorized as retained cases. The extensive documentation of details noted along with patient demographics were mode of trauma, clinical complaints, type of foreign body, site, presentation, time since injury, the details of removal procedure and that of retrieval body, any complications regarding injury or procedure, and period of follow-up were noted apart from patient demographics. A follow-up through complete healing of the wound and beyond for maximum period was obtained in most cases and only cases with at least 4-month duration were included in the present study.


  Results Top


A total of 51 cases with a clinical history of injury with supposed foreign body penetration were identified for the study, of which 6 cases were lost to follow-up within 2 months and thus excluded. Three foreign bodies at sites other than extremities (chest and neck) were also excluded from the study. A final study of 42 cases with at least 4-month follow-up after the treatment were included in the study. Two cases from the study also refused removal, but were longer in follow-up without significant clinical problems and kept as part of the study. Most of the cases resulted from accidental penetration followed by occupational injury in agriculture or industrial settings [Table 1]. There was male predilection with 23 (54.76%) cases as compared [Graph 1], and left side was predominantly involved in 25 (59.52%) cases [Graph 2]. Acral parts such as hand (including digits) and feet (including toes) were involved in majority of cases with a total of 20 (47.61%) cases followed by forearm and wrist with 16.66% and 14.28% of cases (depicted in [Graph 3] and [Graph 4], respectively. The most common age group involved was between 20 and 30 years with 13 (30.95%) cases [Graph 5].
Table 1: Depicting key details of the affected cases and outcome

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The clinical results were excellent in most cases with no functional limitation or need for further surgery except in one case. The number of attempts to successful retrieval was one in most cases except in one case with forearm glass piece when an unsuccessful attempt was done elsewhere. The worse outcome included partial tendon laceration in a case with glass piece at wrist while digital amputation in one case due to extensive soft tissue damage and ischemia.


  Discussion Top


Acute penetrating injuries with foreign body retention are usually easier to diagnose with fresh entry wound and corresponding history. Long-standing retention or inadequate removal poses problem and warrants astute clinicoradiological assessment. Wounds with delayed healing with or without draining sinus should be suspected for implanted foreign body. The conventional imaging like radiography is helpful to diagnose a few of them [Figure 1]c and [Figure 1]d, and majority of nonmetallic bodies require ancillary investigations such as USG or MRI for detection.[4] Most of our cases had clear history of foreign body penetration with or without its complete removal, so in the absence of radiographic evidence, exploration attempt was done around the entry site. Two cases were diagnosed on USG and MRI each. As per the affordability, MRI was not advised to all but only to difficult cases. The cases prescribed the MRI were presented as nodular mass and one with chronic discharging sinus, respectively. Apart from chronic pain and infection, damage to the adjacent structures such as nerve or tendon is reported sequelae of a retained foreign body.[1] We noted it in just one case with sharp glass pieces adjacent to extensor tendon that leads to partial laceration requiring repair [Figure 1]a and [Figure 1]b. One case with forearm glass piece [Figure 2]a and [Figure 2]b and another with hip region metallic splinter also damaged adjacent vein that was ligated during surgery. Apart from delayed or missed detection, one more factor that can make detection of foreign bodies difficult is their migration.[5],[6],[7],[8],[9] The penetration into the deep soft tissue or joints has been reported as well as its concern for leading to onset of tumors.[10],[11],[12],[13] One of our case has long-standing history of deep-seated wooden splinter, leading to recurrent discharge for 18-month duration that on exploration was found to be migrated proximally thrice its length inside flexor tendon sheath. The uneventful recovery and complete healing of the sinus was noted. Discharging sinus was frequent presentation of underlying foreign body in more than 4-month duration in our series [Figure 3]. Only one case had underlying bone osteomyelitis of distal phalanx [Figure 2]c and [Figure 2]d. It is suggested that noninfected wounds with foreign bodies may be planned for elective surgery in view of better light, instrumentation, and aseptic precaution.[14] The acute cases were dealt in emergent removal in the emergency under local or regional anesthesia, while those with retained ones were handled by elective surgery along with cases near major vascular structure. The overall outcome was good in all the cases managed operatively, including the two cases that wished to retain the foreign bodies as it was not affecting activities of daily living. The vegetative and metallic foreign bodies were related to agriculture fields and industrial working environment, respectively, and cautious approach is warranted while within these settings to protect from accidental injury to oneself and others. A proper drafting of vulnerable spots and ameliorative steps is advocated in this regard to avoid similar injuries.
Figure 1: Glass foreign body at wrist clinical picture (a) and radiographs (b) and needle tip in the digits of a child (c and d)

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Figure 2: Radiograph of fluorescent tube light glass piece in volar forearm (a) with retrieved foreign body (b). Chronic pulp space infection of a neglected case (c) with underlying destruction and osteomyelitis in the radiograph (d)

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Figure 3: Chronic discharging infection from lateral ankle region (a) due to retained glass piece seen on radiographs (b) and a case of penetrating wound by sharp wooden splinter over forearm with entry and exit wounds (c)

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The penetrative injuries are not so uncommon entities, but require due management to avoid further complications more so if associated with foreign body retention in full or part. There are few studies about these injuries, but none from Indian subcontinent with respect to types and patterns. The current study presents an overview of common types and locations experienced in a tertiary care setup and is thus helpful to provide a descriptive knowledge of its presence and management. It also stands as preliminary study regarding this injury in hitherto scant literature from this part of the world. As similar studies in other parts are required for a comprehensive outlook on these important injury pattern, prohibitive and ameliorative steps can be drawn on the basis of the present study for a particular geographic region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Anderson MA, Newmeyer WL 3rd, Kilgore ES Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144:63-7.  Back to cited text no. 1
    
2.
Young AS, Shiels WE 2nd, Murakami JW, Coley BD, Hogan MJ. Self-embedding behavior: Radiologic management of self-inserted soft-tissue foreign bodies. Radiology 2010;257:233-9.  Back to cited text no. 2
    
3.
Bennett GH, Shiels WE 2nd, Young AS, Lofthouse N, Mihalov L. Self-embedding behavior: A new primary care challenge. Pediatrics 2011;127:e1386-91.  Back to cited text no. 3
    
4.
Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: Imaging appearance. AJR Am J Roentgenol 2002;178:557-62.  Back to cited text no. 4
    
5.
Merrell JC, Russell RC, Zook EG. Nonsuppurative tenosynovitis secondary to foreign body migration. J Hand Surg Am 1983;8:340-1.  Back to cited text no. 5
    
6.
Yang SS, Bear BJ, Weiland AJ. Rupture of the flexor pollicis longus tendon after 30 years due to migration of a retained foreign body. J Hand Surg Br 1995;20:803-5.  Back to cited text no. 6
    
7.
Chow J, Schenck RR. Foreign body migration in the hand. J Hand Surg Am 1988;13:462.  Back to cited text no. 7
    
8.
Choudhari KA, Muthu T, Tan MH. Progressive ulnar neuropathy caused by delayed migration of a foreign body. Br J Neurosurg 2001;15:263-5.  Back to cited text no. 8
    
9.
Bu J, Overgaard KA, Viegas SF. Distal migration of a foreign body (sago palm thorn fragment) within the long-finger flexor tendon sheath. Am J Orthop (Belle Mead NJ) 2008;37:208-9.  Back to cited text no. 9
    
10.
Devgan A, Mudgal KC. An unusual case of foreign body knee that spontaneously migrated inside and out of the joint: arthroscopic removal. J Hand Surg (America) 2002;27:350-4.  Back to cited text no. 10
    
11.
Ozsunar Y, Tali ET, Kilic K. Unusual migration of a foreign body from the gut to a vertebral body. Br J Neurosurg 2001;15:263-5.  Back to cited text no. 11
    
12.
Pang KP, Pang YT. A rare case of a foreign body migration from the upper digestive tract to the subcutaneous neck. Unfallchirurgie 1994;97:372-4.  Back to cited text no. 12
    
13.
Teltzrow T, Hallermann C, Müller S, Schwipper V. Foreign body-induced angiosarcoma 60 years after a shell splinter injury. Mund Kiefer Gesichtschir 2006;10:415-8.  Back to cited text no. 13
    
14.
Jenkins JL, Loscalzo J, Braen GR: Manual of Emergency Medicine. 3rd ed.. Boston: Little, Brown; 1995.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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